Advancement anoplasty and sacral nerve stimulation: an effective combination for radiation-induced anal stenosis

Introduction  

Pelvic radiotherapy can cause anal stenosis. Patients can be left with severe rectal evacuatory difficulties, anal fissuring and resistant faecal incontinence. The management of such patients is difficult since surgical treatment can worsen faecal incontinence.     

Delayed fecal incontinence following surgery for anal fissure

Purpose  

The surgical treatment of chronic anal fissure is basically done by therapeutic controlled damage to the internal anal sphincter. While fecal incontinence is a well-documented early complication of anal fissure surgery, few data are available about delayed incontinence. The aim of the present study was to assess whether surgical treatment of anal fissures may contribute to the development of delayed anal incontinence.     

Medium-term results of anal advancement flap compared with lateral sphincterotomy for the treatment of anal fissure

Introduction  

Anal fissure is associated with anal pain and bleeding. Lateral internal sphincterotomy (LIS) has been a common form of surgical management. This can however cause incontinence and hence an equally effective alternative without this risk would be ideal. Anal fissurectomy and an anal advancement flap (AAF) have been used as an alternative to LIS.     

Screening for the effectiveness of conservative treatment in chronic anal fissure patients using anorectal manometry

Purpose  

Chemical sphincterotomy (CS) is routinely applied in order to avoid the irreversible anal incontinence associated with the surgical treatment of chronic anal fissure (CAF). However, CS has a lower cure rate than surgery. We developed a screening test (using anal manometry) to separate those patients that are unlikely to benefit from CS and should undergo a more aggressive treatment.     

Sacral nerve stimulation for the treatment of faecal incontinence related to dysfunction of the internal anal sphincter

Purpose  

In patients with faecal incontinence related to isolated internal anal sphincter (IAS) disruption, conservative management is the mainstay of treatment. Surgical repair of the internal sphincter is not successful. This study evaluated the use of sacral nerve stimulation (SNS) in those with faecal incontinence and IAS disruption in whom medical and behavioural treatments had failed.     

Postdelivery anal function in primiparous females

PURPOSE: A study was performed to evaluate the early morphologic and functional consequences of vaginal delivery on the anal sphincter in primiparous females. METHODS: Among a cohort of 197 primiparous females who agreed to participate in a clinical evaluation of fecal incontinence and in a transanal ultrasound examination 12 weeks after delivery, 52 also underwent anal manometry using a radial six-port catheter, of whom 10 were asymptomatic and had a normal sphincter at ultrasound and the remaining 42 had clinical signs of anal incontinence or ultrasonographic defects of the anal sphincter or both. Anal sphincter pressures and asymmetry index were analyzed at rest and during voluntary squeeze. Manometric and ultrasound results were compared, together with clinical symptoms. RESULTS: Fourteen patients with clinical signs of anal incontinence had lower resting and squeeze anal pressures than continent patients (P<0.05), but similar anal asymmetry indexes. Patients with incontinence and an anal defect had the lowest resting and squeeze anal pressures (P<0.05). Forceps assistance to delivery was not associated with a higher frequency of anal sphincter lesions. Resting and squeeze anal pressures were lower in the forceps group (P<0.005), but anal asymmetry indexes were similar. Finally, manometric results were identical in the presence or absence of anal sphincter endosonographic defects. CONCLUSIONS: Anal sphincter defects are frequent after the first vaginal delivery, but are not always associated with functional or clinical abnormalities. Resting and squeeze anal pressures were significantly decreased in patients with incontinence and an anal defect and after forceps-assisted deliveries. Anal asymmetry index was not found useful in this population of young primiparous females.Presented in part at the Journées Francophones de Pathologie Digestive, Paris, France, March 21 to 25, 1998.     

Anal vector volume analysis: an effective tool in the management of pelvic floor disorders

Introduction  

Different trials have investigated the role of conventional anal manometry in the diagnosis of pelvic floor disorders. The aim of the present study is to define the role and the effectiveness of vector anal manometry and vector asymmetry index scoring in the assessment of pelvic floor disorders i.e. fecal incontinence and obstructed defecation.     

Posterolateral versus lateral internal anal sphincterotomy in the treatment of chronic anal fissure: a randomized controlled trial

Background

Lateral internal anal sphincterotomy (LIS) is considered the treatment of choice for chronic anal fissure. This study aimed to compare the outcome of standard LIS and posterolateral internal sphincterotomy (PLIS) at 5 o’clock position as regards healing of anal fissure, improvement in symptoms, and complications.

Methods

Patients with chronic anal fissure were randomly allocated to one of two groups; group I underwent PLIS and group II underwent LIS. Patients were compared regarding the duration of healing of anal fissure, improvement in anal pain as recorded by visual analogue scale (VAS), complications, particularly fecal incontinence (FI) and changes in the anal pressures.

Results

Eighty (49 females) patients were included to this trial. The mean age of patients was 35.5 years. The duration of healing was significantly shorter in group I than in group II (4.1?±?1.7 vs 5.8?±?1.4 weeks; p?<?0.0001). Group I achieved significantly lower pain score at 1 month postoperatively than group II (1.1?±?0.9 vs 1.7?±?0.98; p?=?0.005). Two (2.5%) of group I patients and six (10%) of group II patients experienced minor FI postoperatively. The postoperative reduction in the mean resting anal pressure in group I was significantly higher than that in group II.

Conclusion

Time to complete healing was significantly shorter and pain score was significantly lower after PLIS than after LIS which can be due to more reduction in the resting anal pressure after PLIS. Continence disturbances occurred after PLIS less frequently than after LIS; however, no significant differences between the two techniques were noted.

Trial registration

www.clinicaltrials.gov NCT03426449

     

Systematic review: anal and rectal changes after radiotherapy for prostate cancer

Purpose

Pelvic radiotherapy may lead to changes of anorectal function resulting in incontinence-related complaints. The aim of this study was to systematically review objective findings of late anorectal physiology and mucosal appearance after irradiation for prostate cancer.

Methods

MEDLINE, EMBASE, and the Cochrane library were searched. Original articles in which anal function, rectal function, or rectal mucosa were examined ≥3 months after EBRT for prostate cancer were included.

Results

Twenty-one studies were included with low to moderate quality. Anal resting pressures significantly decreased in 6 of the 9 studies including 277 patients. Changes of squeeze pressure and rectoanal inhibitory reflex were less uniform. Rectal distensibility was significantly impaired after EBRT in 7 of 9 studies (277 patients). In 4 of 9 studies on anal and in 5 of 9 on rectal function, disturbances were associated with urgency, frequent bowel movements or fecal incontinence. Mucosal changes as assessed by the Vienna Rectoscopy Score revealed telangiectasias in 73 %, congestion in 33 %, and ulceration in 4 % of patients in 8 studies including 346 patients, but no strictures or necrosis. Three studies reported mucosal improvement during follow-up. Telangiectasias, particularly multiple, were associated with rectal bleeding. Not all bowel complaints (30 %) were related to radiotherapy.

Conclusions

Low to moderate quality evidence indicates that EBRT reduces anal resting pressure, decreases rectal distensibility, and frequently induces telangiectasias of rectal mucosa. Objective changes may be associated with fecal incontinence, urgency, frequent bowel movements, and rectal bleeding, but these symptoms are not always related to radiation damage.     

Fistulectomy with primary sphincter reconstruction in the treatment of high transsphincteric anal fistulas

Purpose

The treatment of transsphincteric anal fistulas is a challenge between recurrence rate and incontinence. Many surgical and conservative procedures have been described in the treatment of anal fistulas. Fistulectomy and primary sphincter reconstruction (FPSR) has not gained great popularity in this field due to the risk of sphincter damage. The aim of this study is to evaluate FPSR in the treatment of transsphincteric fistulas.

Methods

We retrospectively analyzed 50 patients with high transsphincteric fistulas of cryptoglandular origin that were treated with FPSR between 2005 and 2008. Preoperative assessment included physical and proctologic examination. Continence and pain scores were evaluated preoperatively and postoperatively.

Results

In our 50 patients, 22 patients (44 %) had a previous proctologic operation and 11 patients (22 %) presented with recurrent fistulas. The fistulas existed for an average of 8 months. The operation time was 28?±?16 min. Mean follow-up was 22± months. The fistula healed in 44 patients (88 %) who developed no recurrence. In five patients (10 %), the fistula healed, but they developed a recurrence in the observation period. In one patient (2 %), the fistula did not heal. Three patients developed low-grade incontinence for flatus, and one patient with 2° incontinence improved. Preoperatively and postoperatively calculated continence and pain scores showed a slight but significant elevation in the Clinical Continence Score, the German Society of Coloproctology Score showed no significant difference, and preexisting pain was reduced significantly by surgery.

Conclusions

FPSR is a safe surgical procedure for the treatment of high transsphincteric anal fistula. The primary healing rate is high with a low risk of recurrence or incontinence.     

A pilot comparative study of fissurectomy/diltiazem and fissurectomy/botulinum toxin in the treatment of chronic anal fissure

Background  

Treatment of chronic anal fissure (CAF) by fissurectomy with botulinum toxin A (BTA) injection results in a healing rate of greater than 90%. BTA injection, however, can cause incontinence and perianal sepsis. The decrease in sphincter pressure following topical treatment with 2% diltiazem cream (DTC) is comparable to that following BTA injection but with potentially fewer complications and at less cost. We report the shortterm results of a pilot study comparing fissurectomy with BTA and fissurectomy followed by DTC for the treatment of CAF.     

The relationship between etiology,symptom severity and indications of surgery in cases of anal incontinence: a 25-year analysis of 1,046 patients at a tertiary coloproctology practice

Background  

The etiology of anal incontinence (AI) is often multifactorial. There is little data on the relationship between the etiology of AI, symptom severity, and the need for surgery. The aim of our study was to investigate this association in a large number of unselected patients with AI referred to a tertiary specialist coloproctological practice.     

Poor outcome of sphincter repair: an evacuation problem?

Introduction  

Colorectal transport in idiopathic fecal incontinence has scarcely been studied, and it remains to be investigated in patients with fecal incontinence and anal sphincter lesion. The aim of the present study was to compare colorectal transport during defecation in patients with idiopathic fecal incontinence and patients with fecal incontinence due to anal sphincter lesions with transport in healthy volunteers.     

Long-term outcome after overlapping anterior anal sphincter repair for fecal incontinence

Purpose

The aim was to assess long-term results and quality of life following anterior anal sphincter repair for anal incontinence.

Patients and methods

Twenty-three female patients underwent anterior anal sphincteroplasty over a 10-year period between January 1999 and January 2009 in a gynecological surgery department. Patients were asked to complete pre- and postoperative questionnaires comprising the Jorge and Wexner incontinence score. The secondary objective was to assess pre- and post-sphincteroplasty symptom severity and sexual quality of life. Mean follow-up was 87 months (median, 91.5 months). Kaplan-Meier time-to-event analysis was applied.

Results

Mean age was 52 years (±15.2), and mean postoperative Jorge and Wexner score, 7.5/20 (±4.1). Seventeen patients (85 %) declared themselves satisfied by the repair; 12 (60 %) showed good fecal continence. Fecal incontinence had a negative impact on quality of life for 15 % and on sexuality for 50 % of patients. Kaplan-Meier analysis showed 85 % conservation of anal continence correction at 1 year, 74 % at 48 months, 67 % at 60 months, and 48 % at 84 months.

Conclusions

Overlapping anterior anal sphincter repair provided lasting improvement in fecal incontinence, with satisfactory long-term functional results. At 84 months’ follow-up, 48 % of patients maintained good fecal continence, with a satisfaction rate of 85 %. Anal sphincteroplasty may be a first-line attitude in young female fecal incontinence patients with a recent sphincter defect following initially undiagnosed obstetric trauma and also restores perineal comfort.     

Combined partial fistulectomy and electro-cauterization of the intersphincteric tract as a sphincter-sparing treatment of complex anal fistula: clinical and functional outcome

Background

The aim of this study was to report a simple, effective and safe procedure, associated with minimal risk of incontinence and recurrence, for treating complex anal fistulas.

Methods

This was a prospective study of 53 consecutive patients with complex anal fistulas. The technique used included excision of the distal part of the fistula tract down to the external anal sphincter and electro-cauterization of the intersphincteric part of the tract with simple closure of the internal opening. Data collected included patient characteristics, fistula type determined by magnetic resonance imaging, pre- and postoperative continence status evaluated using the Wexner incontinence score (0–10), previous operations, hospital stay, healing time, recurrence rate and complications.

Results

The patients had a mean age of 41.37 ± 7.82 years; the most frequent fistula type was the high transsphincteric fistula; the mean follow-up period was 19 months with a success rate of 92.5 %; the mean wound healing time was 3.6 weeks; the incontinence scores were the same as before the procedure. The recurrence rate was 7.5 %.

Conclusions

Partial fistulectomy combined with electrocauterization of the intersphincteric fistula tract is a simple, and effective procedure for the treatment of complex anal fistulas.     

Quality training in laparoscopic colorectal surgery: does it improve clinical outcome?

Background  

Millions of people suffer from anal incontinence not currently treated due to the complexity and cost of the surgical techniques in use. The purpose of this report is to evaluate the results of anal encirclement with a simple device in a group of patients with faecal incontinence of multiple causes.     

A prospective non-randomized two-centre study of patients with passive faecal incontinence after birth trauma and patients with soiling after anal surgery, treated by elastomer implants versus rectal irrigation

Aim

This study is a prospective evaluation of patients with passive faecal incontinence and patients with soiling treated by elastomer implants and rectal irrigation.

Patients and methods

Patients with passive faecal incontinence after birth trauma resulting from a defect of the internal sphincter and patients with soiling after previous anal surgery were included. All patients underwent endo-anal ultrasound, magnetic resonance imaging, and anal manometry. The patients with passive faecal incontinence were initially treated by anal sphincter exercises and biofeedback therapy during half a year. The patients completed incontinence scores, a quality of life questionnaire, and a 2-week diary card.

Results

The elastomer group consisted of 30 males and 45 females with a mean age of 53?years (25–77). The rectal irrigation group consisted of 32 males and 43 females with a mean age of 50?years (25–74). At 6?months follow-up, 30 patients with soiling of the rectal irrigation group and only nine patients of the elastomer group were completely cured (p?=?0.02). Only three patients with passive faecal incontinence were cured in the rectal irrigation group and none in the elastomer group. Three distal migrations of elastomer implants required removal at follow-up.

Conclusions

After patients had performed anal sphincter exercises, no clear improvement of passive faecal incontinence was obtained by elastomer implants or rectal irrigation. However, rectal irrigation is far more effective than elastomer implants in patients with soiling.     

Anal physiology testing in fecal incontinence: is it of any value?

Introduction  

The prognostic value of postoperative manometry in fecal incontinence is still controversial. The aims of this study were to establish if Fecal Incontinence Severity Index (FISI) and Fecal Incontinence Quality of Life Scale (FIQL) scores correlate with anal manometry and endoanal ultrasound findings and to define if there is any prognostic value in performing anal manometry after patients are surgically treated for fecal incontinence.     

Manometric asymmetry in the anal canal in controls and patients with fecal incontinence

PURPOSE: This study was designed to ascertain the existence of manometric asymmetry in the anal canal in controls and in patients with fecal incontinence. METHODS: A computerized manometric technique with an eight-channel perfusion catheter was used. Coefficient of variation (CV, a mathematical expression of the degree or magnitude of deviation of a set of data points from the mean) was developed in this study as an index of anal canal manometric asymmetry. RESULTS: At 1 cm from the anal verge, mean CV was 9.3 and 8.7 percent in asymptomatic control males and females, respectively. During a maximum voluntary squeeze effort, mean CV in control males was 9.3 percent and was not significantly different (P =0.28) from that in control females (7.8 percent). In 14 consecutive female patients with fecal incontinence, mean CV at rest (1 cm from the anal verge) was 21 percent and was significantly higher (P <0.01) than in control females. Similarly, during a maximum voluntary squeeze effort, mean CV in patients with fecal incontinence was 20.5 percent and was significantly higher (P <0.01) than in the female control group (7.8 percent). CONCLUSION: It is concluded that CV, a method of expressing anal sphincter manometric asymmetry, is a useful manometric parameter in the assessment of anorectal function.     

Pudendal nerve terminal motor latency testing does not provide useful information in guiding therapy for fecal incontinence

Purpose

Pudendal nerve terminal motor latency (PNTML) testing is a standard recommendation for the evaluation of fecal incontinence. Its role in guiding therapy for fecal incontinence has been previously questioned. The aim of this study was to evaluate the relationship between PNTML testing and anorectal dysfunction.

Methods

This was a retrospective analysis of data collected prospectively from patients who presented to a pelvic floor disorder center from 2007 to 2015. The relationship between PNTML (normal versus delayed) and anorectal manometry, fecal incontinence severity, and fecal incontinence-related quality of life scores was assessed using the Wilcoxon-Mann-Whitney test.

Results

Two hundred sixty-nine patients underwent PNTML testing, and 91.1% were female (N?=?245) (median age 62.2 years). Normal PNTML was seen in 234 (87.0%) patients. Among 268 patients who underwent anorectal manometry, delayed PNTML was only significantly associated with median maximum anal squeeze pressure (P?=?0.04). Delayed PNTML was not associated with a decrease in median fecal incontinence severity or fecal incontinence-related quality of life scores (N?=?99).

Conclusions

PNTML was only associated with median maximum anal squeeze pressure, and it was not associated with patient-reported severity of symptoms of fecal incontinence, changes in quality of life attributable to fecal incontinence, median mean resting anal pressure, or median maximum resting anal pressure. PNTML testing may not be relevant to current therapeutic algorithms for fecal incontinence and its routine use should be questioned.